Abstract

Objective To describe physician perspectives on the causes of and solutions to obesity care and identify differences in these perspectives
by number of years since completion of medical school.

Design National cross-sectional online survey from 9 February to 1 March 2011.

Setting USA.

Participants 500 primary care physicians.

Main Measures We evaluated physician perspectives on: (1) causes of obesity, (2) competence in treating obese patients, (3) perspectives
on the health professional most qualified to help obese patients lose or maintain weight and (4) solutions for improving obesity
care.

Results Primary care physicians overwhelmingly supported additional training (such as nutrition counselling) and practice-based changes
(such as having scales report body mass index) to help them improve their obesity care. They also identified nutritionists/dietitians
as the most qualified providers to care for obese patients. Physicians with fewer than 20 years since completion of medical
school were more likely to identify lack of information about good eating habits and lack of access to healthy food as important
causes of obesity. They also reported feeling relatively more successful helping obese patients lose weight. The response
rate for the survey was 25.6%.

Article summary

Article focus

The purpose of this study is to describe primary care physician (PCP) perspectives on the causes of and solutions to obesity
care and whether these perspectives differ by number of years since completion of medical school.

We hypothesised that PCPs with a shorter duration of time since completing medical school (less than 20 years) would be more
likely to identify environmental factors (rather than biological or individual factors) as the cause of obesity, feel more
competent providing obesity-related care and be more likely to identify increased training and practice-based changes as possible
solutions to the problem of obesity.

Key messages

There are few differences in PCP perspectives about the causes of obesity or solutions to improve care, regardless of when
they completed medical school, suggesting that obesity-related medical education has changed little over time.

Regardless of when PCPs completed medical school, they overwhelmingly supported additional training and practice-based changes
to help them improve their obesity care.

Strengths and limitations of this study

The key limitation of this study is that our measures of physician attitudes do not represent the full possible spectrum of
attitude measures in the literature (such as perceived skills or comfort in caring for obese patients) which may bias our
results towards the null

The key strength of this study is that it uses a national sample of PCPs.

Obesity affects one-third of the US adult population1 and is estimated to cost $147 billion annually.2 Despite national guidelines for primary care physicians (PCPs) to counsel their obese patients to lose weight,3,4 only one-third of obese patients report receiving an obesity diagnosis or weight-related counselling.5

While there is a growing body of research documenting physician perspectives on the causes of obesity,6–8 little research has examined PCP perspectives on possible solutions to improve obesity care. This is an important area of
research given that PCPs are in a unique position to treat obesity and assist with healthy-weight maintenance. In 2008, there
were an estimated 455 million visits were made to PCPs.9 Given the penetration of the obesity epidemic, even modest reductions in body weight at the individual level can lead to
significant health benefits and reduced costs at the population level.10,11

Physician-level barriers to obesity care have been extensively explored in the literature. Many of the physician-level barriers
relate to clinical knowledge and attitudes towards obese patients including: inadequate training in weight counselling, poor
knowledge of the tools needed to diagnose and treat obesity.7,12–14 negative physician attitudes (eg, weight stigma, pessimism about patient's desire/ability to lose weight; belief that weight-loss
counselling is ineffective,15–18) doubt that counselling will have an effect on patient behaviour,19,20 and feeling that obesity is the responsibility of the patient.21

Some of these physician barriers may be related to how recently PCPs completed medical school or residency. Little research
has explored the association between years since completion of medical training and physician perspectives on obesity. The
available evidence suggests a positive correlation between years since residency and a negative expectation of outcomes for
obese patients among internists, paediatricians, and psychiatrists.22 Previous research has also shown that years since medical school predicts the types of treatment offered to obese patients,
where physicians who completed medical school ≥20 years before the study were more likely to provide general counselling,
specific dietary counselling, specific physical activity counselling, and to systematically track patients than those who
completed their training <10 years ago.23

This is an important area of research given that obesity training can improve the quality of physician practice patterns of
obesity care (such as weight-related counselling),24 and new cohorts of medical students and residents may be more likely to receive this training as compared with older cohorts.
Physicians who learn appropriate obesity screening and counselling practices in residency are more likely to report discussing
diet or exercise with their obese patients.12 Recent graduates may also be more likely to consider modest weight loss or weight maintenance a successful outcome.

Our primary goal was to describe physician perspectives on the causes of obesity and solutions to improve care of obese patients
in the healthcare system. Our secondary goal is to identify differences in these perspectives by the number of years since
completion of medical school. We examined differences in perspectives by years since completing medical school for the following
topics: causes of obesity, competence in treating obese patients, perspectives on the health professional most qualified to
help obese patients lose or maintain weight, and solutions for improving obesity care. We hypothesised that physicians with
a shorter duration of time since completing medical school (less than 20 years) would be more likely to identify environmental
factors (rather than biological or individual factors) as the cause of obesity, feel more competent providing obesity-related
care, and be more likely to identify increased training and practice-based changes (eg, appropriateness of medical equipment)
as possible solutions to the problem of obesity. This research updates earlier studies focused on physician attitudes towards
obesity causes and treatment6,8 as well as provides physician perspectives about solutions to obesity care with an emphasis on whether perspectives differ
according to when physicians completed medical school.

Methods and procedures

Study design

National cross-sectional internet-based survey of PCPs in the USA.

Survey development and implementation

We consulted SSRS/Social Science Research Solutions to design and implement the survey. The survey instrument was reviewed
for content by physicians and experts in the field of obesity, and was then pretested for length and comprehensibility. The
survey was revised on the basis of these pilot tests and the final version included 49 questions. A total of 10 pretest interviews
were conducted by inviting panel members to participate in the study and asking them for comments they had about any of the
questions. Following the pretest, several changes were incorporated into the final questionnaire. For example, we changed
the response categories for some questions and the stem question for others. The pilot interviews were conducted by the survey
firm (Social Science Research Solutions) which is external to Hopkins. Two polling experts from Social Science Research Solutions
also reviewed the survey for comprehensibility. Four obesity experts, internal to Hopkins, commented on the content of the
survey questions. The fieldwork for this survey was conducted via the internet by The Epocrates Honors Web Panel Company,
which consists of 145 000 physicians.

We surveyed 500 general practitioners, family practitioners and general internists between 9 February and 1 March 2011. These
physicians were recruited from The Epocrates Honors panel. The Epocrates Honors panel is an opt-in panel of 145 000 physicians
in the USA verified by the American Medical Association's (AMA's) master file. Physicians were verified by checking their
first and last name, date of birth, medical school and graduation date against the AMA's master file at the time of panel
registration. A random sample of the panel was invited to participate in the survey. This sample was drawn to match AMA master
file proportions for age, gender, and region. Each physician received a $25 incentive for completing the survey. Consent to
participate was obtained by physicians choosing to complete the survey.

This study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board and determined to
be exempt.

Measures of physician perspectives on obesity care

We evaluated physician perspectives on the following topics: (1) causes of obesity, (2) competence in treating obese patients,
(3) perspectives on the health professional most qualified to help obese patients lose or maintain weight and (4) solutions
for improving obesity care.

We assessed physician beliefs about the causes of obesity with the question, “How important is each of the following possible
causes of obesity for your patients?” For each cause (overconsumption of food, restaurant/fast food eating, consumption of
sugar-sweetened beverages (SSB), genetics/family history and metabolic defect), physicians indicated whether it was very important,
somewhat important, not very important, or not at all important. We dichotomised variables for each cause where 1 was ‘very/somewhat
important’ and 0 was not ‘very/not at all important’. We categorised all of the causes of obesity into three categories (biological,
individual behaviours and physical/social environmental factors) based on the conceptual frameworks described by the 2005
and 2012 Institute of Medicine reports on obesity.25,26 Physical/social environmental factors refer to things which influence individual behaviours but which are typically outside
of a person's control.

Physician competence questions assessed by the question, “Please tell me whether you agree or disagree with the following
statements: I feel competent giving diet counseling to my obese patients; I feel competent giving exercise counseling to my
obese patients; and I am usually successful in helping my obese patients lose weight.” For each statement, physicians indicated
whether they strongly agreed, somewhat agreed, somewhat disagreed or strongly disagreed with the statements. We dichotomised
variables for each competency where 1 was ‘strongly/somewhat agree’ and 0 was ‘strongly/somewhat disagree’.

We assessed perspectives about how to improve obesity training among those physicians who had already received some additional
training with the survey question, “Since you have received more training on how to care for your obese patients, how helpful
would each of the following types of training be: Nutrition counseling, exercise counseling, patient care after bariatric
surgery, patient eligibility for bariatric surgery, motivational interviewing, and weight loss medications.” For each type
of training, physicians indicated whether they believed it would be very helpful, somewhat helpful, not very helpful, or not
at all helpful. We dichotomised variables for each type of training where 1 was ‘very/somewhat helpful’ and 0 was ‘not very/not
at all helpful’. Among all physicians, we assessed the perspectives about improving obesity care with the following questions:
“How helpful would it be for the patient chart to include a specific list of diet and exercise tips you could share with your
obese patients to help them lose weight or manage their weight?”; “How helpful would it be for scales that measure height
and body weight to also report body mass index so that medical assistants/nurses are not required to calculate it?”; “If it
does not already, how helpful would it be if the medical chart clearly indicated whether the patient was clinically obese
or overweight (by including BMI and the overweight/obesity status)?”; and “How important is it to include body mass index
with patients’ other vital signs of heart beat, breathing rate, temperature, and blood pressure?” We dichotomised variables
for each type of improvement as 1 was ‘very/somewhat helpful’ and 0 was ‘not very/not at all helpful’. Finally we assessed
the perspectives about medication equipment with the question, “How appropriate is the medical equipment in your office for
your obese patients (eg, gowns, chairs, exam tables, blood pressure cuffs)?” and dichotomised the response categories as 1
‘very/somewhat appropriate’ and 0 ‘not very/not at all appropriate’.

Statistical analyses

We performed descriptive analyses for all variables. t-Tests were used to test for differences by years since completing medical
school. We used weighting to address systematic under-representation or over-representation of the physician subpopulations
in the panel, account for systematic non-response along known demographic characteristics of the PCPs, and adjust for sampling
biases due to differences in non-response rates.

All analyses were stratified based on years since completing medical school, comparing physicians who completed medical school
fewer than 20 years ago (ie, 1991 or later) with PCPs who completed medical school 20 or more years ago (ie, 1990 or earlier).
The weighted mean year that medical school was completed in our sample was 1993. We elected to stratify by the 20-year threshold
based on previous research suggesting differences in counselling and tracking of obese patients among those two groups of
physicians.23 We also conducted sensitivity analyses using 10 and 15 years since medical school as the thresholds. Those results are not
included as they did not differ substantively from the 20-year cut points. They are available from the authors upon request.
Statistical analyses were performed using the STATA, V.11.0 software package (StataCorp LP, College Station, Texas, USA),
using SVY functions to adjust for the complex survey design. The weighted margin of error for the survey was ±5.3%.

Results

Of the 145 000 physicians, 2010 email addresses were sent invitations 58 were returned as undeliverable. The response rate,
calculated as completed interviews over the total of working emails sent an invitation was 25.6%.

Sample characteristics

Table 1 shows characteristics of the survey respondents. Physician-level characteristics are comparable to national-level characteristics
reported for family physicians/internists/general practitioners by the AMA, with the exception of the distribution of years
since completing medical school. Our sample distribution had slightly more respondents who had completed medical school recently
(in 2000) than the national sample reported by the AMA (22% vs 21%). Specifically, 49% of physicians in the AMA sample completed
medical school in 1990 or later, compared with 69% in our sample. A large majority of PCPs (84%) reported that about half
of the patients in their practice were obese, and 10% reported that almost all patients in their practice were obese. Nearly
all physicians reported that patient height and body weight were included in patients’ charts, and 76% reported that body
mass index (BMI) was included in patients’ charts. When asked to rate the quality of obesity-related training, 23% reported
receiving good training in medical school, 35% reported receiving good training in residency and 60% reported receiving good
training in continuing medical education.

PCP perspectives on causes of obesity

Table 2 describes PCP perspectives on the causes of and solutions to obesity care as well as differences in these perspectives by
number of years since completion of medical school (≥20 vs <20 years). We divided possible causes of obesity into three domains:
individual biological factors, individual behavioural factors and physical/social environmental factors. Overall, 75% of PCPs
identified genetics or family history as an important cause of obesity, followed by metabolic effect (47%) and endocrine disorders
(25%). Individual behavioural factors were the most commonly reported causes of obesity, with nearly all physicians citing
insufficient physical activity (99%), overconsumption of food (99%), restaurant or fast-food eating (95%), consumption of
SSBs (94%) and lack of will power as important causes of obesity (89%). PCPs also identified environmental factors as important
causes of obesity: cultural factors (85%), lack of information on good eating habits (75%) and lack of access to healthy foods
(59%).

Primary care physician perception of the importance of possible causes of obesity, overall and by years since completing medical
school, N (%)

We observed few differences in perspectives about possible causes of obesity between physicians who had completed medical
school ≥20 years ago compared with those who had completed medical school <20 years ago. PCPs who completed medical school
recently were more likely to identify restaurant or fast-food eating (99% vs 90%; p<0.01), lack of information on good eating
habits (80% vs 69%; p=0.03), and lack of access to health foods as important causes of obesity (64% vs 52%; p=0.03).

PCP perspectives in improving care for obese patients

Table 3 shows PCP perspectives on the healthcare provider most qualified to help obese patients lose or maintain weight, stratified
by years since completing medical school. No one type of provider was endorsed by a majority of PCPs as the most qualified
to help patients. PCPs with <20 years since completion of medical school reported that nutritionists/dietitians were most
qualified providers (48% vs 41%), followed by PCPs 41% vs 37%) and behavioural psychologists (9% vs 20%, p=0.01). Very few
PCPs reported that endocrinologists (1% vs 1.5%) or nurses (1% vs 1%) were the most qualified providers to help obese patients
lose or maintain weight.

Physician perspectives on health professional most qualified to help obese patients lose or maintain weight, by years since
completing medical school N (%)

PCP perspectives on solutions for improving obesity care

Table 4 shows PCP perspectives on solutions for improving obesity care related to physician training and practice-based changes.
With respect to training, PCPs who had received some training in obesity-related care (n=313) generally reported that it was
helpful. In terms of practice-based solutions to improving care, 93% reported that including BMI as a fifth vital sign would
be helpful; 89% reported that including diet/exercise tips in patients’ charts would be helpful; 85% reported that having
scales report BMI would be helpful; and 69% reported that adding BMI to patients’ charts would be helpful. No significant
differences were observed by year since completing medical school with one exception. Fewer PCPs who completed medical school
within 20 years agreed that BMI reported by scales would be being helpful in treating obese patients (81% vs 89%; p=0.02).

Discussion

This study updates earlier research related to PCP perspectives on the causes of obesity and examines physician-reported causes
of obesity and solutions for improving obesity care, for PCPs overall and by years since medical school completion. Like previous
research,6,27,28 we found that PCPs overwhelmingly identified individual behavioural factors (eg, poor diet and physical inactivity) as important
causes of obesity. PCP perspectives on improving obesity care supported additional training (eg, nutrition and exercise counselling)
and practice-based changes (eg, including BMI in the patient chart). We observed few differences in PCP perspectives about
the causes of obesity or solutions to improve care, regardless of when they completed medical school. However, we found PCPs
who graduated from medical school within the past 20 years, compared with those with graduated more than 20 years ago, more
frequently recognised social determinants as causes of obesity, such as lack of information about good eating habits and lack
of access to healthy food. While PCPs who completed medical school more recently reported feeling more successful helping
obese patients lose weight, these successful providers are still a minority. This is consistent with research suggesting that
PCPs generally feel unprepared to care for obese patients.7,12–14 Increased time since completing medical school could lead to more negative attitudes towards obesity care, as physicians
may become frustrated by years of failed attempts to help their obese patients lose and maintain weight. Regardless of when
PCPs completed medical school, they overwhelmingly supported additional training and practice-based changes to help them improve
their obesity care.

The limited differences among PCPs that we observed may suggest that obesity-related training has changed little over time.
We found little evidence that any recent emphasis on obesity-related training in medical school has translated into significant
differences in self-perceived competency. Interestingly, while most PCPs reported competence in diet and exercise counselling
to obese patients, less than half-reported success in helping those patients lose weight.

Given that obesity training has been shown to improve obesity care,12 improvements to medical and postgraduate medical education are critical. As most practising PCPs report inadequate training
in obesity care, these physicians may be particularly receptive to continuing medical education in this area.13,14 PCPs in our study desired additional training on nutrition and exercise counselling, care related to bariatric surgery patients,
as well as motivational interviewing. Enhancements to medical education could potentially help improve obesity care given
research suggesting consistency between physician beliefs about solutions and causes;29 for example, physicians who endorse medical solutions for obesity typically believe obesity is caused by biological factors.
In addition to addressing these gaps in medical education, we should consider transitioning some obesity care responsibilities
away from PCPs to nutritionists/dietitians. Physicians in our study identified these health professionals as being most qualified
to help obese patients lose or maintain their weight. Furthermore, incentives for care coordination under the Patient Protection
and Affordable Care Act such as the Patient Centered Medical Home recommend the inclusion of dietitians as members of health
teams to support primary care practices.30 Perhaps a new model of obesity care should join PCPs, nutritionists, and other relevant health professional together—an approach
which proved effective in the recently completed POWER trial,31 which examined the effects of behavioural weight-loss interventions among obese patients.

Future research is needed to better understand which components of obesity care would be best handled by PCPs and which components
of obesity care would be best handled by nutritionists/dietitians. Recent work identifies successful models that include delivery
of weight loss support by trained coaches via remote means (eg, telephone, email, and web-based modules, self-monitoring tools
and feedback) along with PCP support31 and lifestyle counselling plus meal replacement or weight-loss medication chosen in consultation with the PCP.32

Regardless of their years after medical school completion, most physicians desired practice-based changes to facilitate improved
obesity care. Physicians endorsed using appropriate medical equipment to accommodate obese patients, as well as documenting
BMI in the chart as important practice changes. Such changes would ensure accurate identification and proper care of obese
patients. Finally, the practice could better support obesity counselling by including diet and exercise tips in the chart
for the physician to use.

There are several limitations to this analysis. First, our measures of physician attitudes do not represent the full possible
spectrum of attitude measures in the literature (such as perceived skills33 or comfort in caring for obese patients34) which may bias our results towards the null. Second, some of the included PCP's may have had extensive additional training
in obesity (considering themselves ‘obesity specialists’), which could have biased our results positively. Years since medical
school completion is a proxy for type of education they received, but we are unable to account for the huge variation in curricula
across medical schools. Third, even though they survey was reviewed by experts in the field of obesity and primary care as
well as pilot tested for comprehensibility, it is possible that physicians differentially interpreted some of the questions.
Fourth, the response rate may limit the generalisability of these results to all PCPs in the USA.

In conclusion, this study suggests few differences in PCP perspectives about the causes of obesity or solutions to improve
care of obese patients, regardless of when they completed medical school. The differences we did observe suggest that physicians
with fewer than 20 years since completion of medical school more frequently recognised social determinants as causes of obesity
and also reported feeling more successful helping obese patients lose weight. The results from the recently completed POWER
trial, suggest that having PCPs play a supportive role to weight loss health coaches—such as reviewing patient progress and
using this information to provide basic guidance and motivation—may be one effective model.31 In order to begin improving obesity care, medical education should focus on enhancing those obesity-related skills PCPs feel
most qualified to deliver as well as changing the composition of healthcare teams and practice resources.

Footnotes

Contributors SNB and LAC conceived the study. SNB analysed the data. All authors contributed to the interpretation of study findings.
SNB drafted the manuscript and all authors contributed to the final draft. SNB had full access to all of the data in the study
and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Funding This work was supported by three grants from the National Heart, Lung, and Blood Institute (1K01HL096409, K24HL083113, and
P50 HL0105187) and one grant from the Health Resources and Services Administration (T32HP10025–17-00).

North American Association for the Study of Obesity (NAASO) and the National Heart Lung and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report.
National institutes of health. Obes Res1998;6(Suppl 2):51S–209S.